Tracheal intubation (TI) is a common, life-saving procedure for critically ill children treated in Pediatric ICUs, but associated with frequent complications and adverse safety outcomes. TI in critically ill children is challenging because of low oxygen reserve, unstable hemodynamics, and airway anatomy. Despite these safety risks and unique challenges for TI in pediatric ICUs, reliable prospective multi-center data to characterize our current practice and identify opportunities for quality improvement is not available. Our preliminary prospectively-collected data from a single pediatric ICU documented TIs are common (one in every 2.5 days in 45 beds ICU) and unwanted TI associated events (adverse safety outcomes) occur in >20% . However, these findings cannot be simply generalized because the incidence of TIs and unwanted TI associated events are highly dependent on patient, provider and practice characteristics. Thus, it is critically important to develop and implement a prospective database to capture the current practice across diverse pediatric ICUs with uniform operational definitions and near 100% data compliance without reporting bias. This project will expand our single-center pediatric TI registry: National Emergency Airway Registry for Children (NEAR4KIDs) to a diverse spectrum (large to small, academic to private) of PALISI participating pediatric ICUs. We will advance and expand the registry with the following strategies: 1. Implement high compliance data capture and crosscheck system 2. Use prospectively defined consensus operational definitions 3. Verify and crosscheck the data 4. Develop a standard consensus reporting system to document the process variances and outcomes that impact patient safety. Upon completion of this pilot project, we will have used prospective multi-center data to characterize the current practice and identify evidence-based opportunities for quality improvement and research across a diverse network of pediatric ICUs. We will identify key candidate variables for future interventional studies that could improve patient safety. This proposed RO3 project is an essential bridge from our single center TI safety experience to multi-center clinical trials that will ultimately improve the outcome of critically ill children across the US and the world. PUBLIC HEALTH RELEVANCE: Rescuing critically ill children from respiratory failure by placing a tube in the airway to support breathing is a common, high risk procedure in pediatric intensive care units (PICUs) that often results in complications. Our research network of 15 diverse PICUs will characterize the landscape of current practice and factors associated with risks and complications as future quality improvement targets. This is the critically important next step to improve safety and outcomes of children who need respiratory support across broad spectrum of PICUs.